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Review: Attachment and attachment-related outcomes in preschool children – a review of recent evidence Barlow, J. , Schrader-McMillan, A. , Axford, N. , Wrigley, Z. , Sonthalia, S. , Wilkinson, T. , Rawsthorn, M. , Toft, A. and Coad, J. Author post-print (accepted) deposited by Coventry University’s Repository Original citation & hyperlink: Barlow, J. , Schrader-McMillan, A. , Axford, N. , Wrigley, Z. , Sonthalia, S. , Wilkinson, T. , Rawsthorn, M. , Toft, A. and Coad, J. (2016) Review: Attachment and attachment-related outcomes in preschool children – a review of recent evidence. Child and Adolescent Mental Health, volume 21 (1): 11-20
http://dx.doi.org/10.1111/camh.12138 DOI 10.1111/camh.12138 ISSN 1475-357X ESSN 1475-3588 Publisher: Wiley This is an Accepted Manuscript of an article published by Taylor & Francis in Child and Adolescent Mental Health on 25th November 2015, available online: http://www.tandfonline.com/10.1111/camh.12138 Copyright © and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. This document is the author’s post-print version, incorporating any revisions agreed during the peer-review process. Some differences between the published version and this version may remain and you are advised to consult the published version if you wish to cite from it.
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Child and Adolescent Mental Health
Interventions to Improve Attachment in Preschool Children: A review of recent evidence
Jane Barlow (1), Nick Axford (2), Anita Schrader-McMillan (1), Zoe Wrigley (2), Shreya Sonthalia (2), Tom Wilkinson (2) and Michaela Rawsthorne (2), Alex Toft (3) Jane Coad (3). (1) Warwick Medical School, University of Warwick (2) Dartington Social Research Unit (3) Coventry University Abstract
Background: Secure attachment is associated with better outcomes across all
domains in childhood, with insecure and disorganised attachment being
associated with a range of later psychopathologies. This is of concern because
insecure and disorganised attachment is common, particularly in disadvantaged
populations.
Aims: This paper presents the findings of a review of secondary and primary
studies evaluating the effectiveness of interventions aimed at improving
attachment-related outcomes on a targeted or indicated basis, which was
undertaken as part of an update of the evidence base for the Healthy Child
Programme 0-5 Years.
Method: A systematic search of key electronic databases was undertaken to
identify secondary and primary sources of data addressing the research
question, and that had been published between 2008 and 2014.
Findings: Six systematic reviews and 10 RCTs were identified that had evaluated
the effectiveness of selective or indicated interventions aimed at improving
attachment-related outcomes in children aged 0-5 years. Effective methods of
working include video feedback, home visiting programmes, and parent-infant
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psychotherapy. Promising methods of working include mentalisation-based
programmes and group-based parenting programmes such as Mellow Babies.
Conclusions: A number of methods of working to promote attachment-related
outcomes are now being recommended as part of the Healthy Child Programme
to improve attachment related outcomes in preschool children. The implications
in terms of the role and contribution of CAMHS practitioners are discussed.
Key Practitioner messages
This review has identified a range of innovative methods of working that
have been found to improve outcomes that are associated with
attachment, including parental sensitivity;
The identified interventions are not yet routinely available in the UK;
Although the methods of working and the underpinning theories of
change are diverse, the review has identified some potentially core skills
required by practitioners working with preschool children including
mentalisation-based techniques and videofeedback.
Some of the more specialist interventions should be offered by CAMHS
practitioners.
Key words: Healthy Child Programme; 0 – 5 years; targeted intervention;
attachment; parental sensitivity; early years
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Background
Attachment security has been identified as being significantly associated with a
range of improved outcomes for children across all domains of functioning
including emotional, social and behavioural adjustment, scholastic achievement
and peer-rated social status (Sroufe, 2005), while both insecure and
disorganised attachment are associated with a range of later problems (van der
Voort et al., 2014), including externalising disorders (Fearon et al., 2010),
dissociation (Lyons-Ruth et al., 2006), PTSD (MacDonald et al., 2008) and
personality disorder (Steele & Siever, 2010). For example, one longitudinal
follow-up study of children disorganised at 1-year of age found that by six years
of age the children were showing signs of controlling behaviours toward the
parent, avoidance of the parent, dissociative symptoms,
behavioural/oppositional problems, emotional disconnection, aggression toward
peers and low social competence in preschool (Lieberman & Amaya-Jackson,
2005).
These issues are of concern because current data suggests that only two thirds of
children are securely attached, and that disorganised attachment has a
prevalence of 15-19% in population samples (De Wolff & Van Ijzendoorn, 1997);
up to 40% in disadvantaged populations (e.g. Weinfield, 2004; Carlson, 1998);
and as many as 80% in maltreated populations (Cyr et al., 2010; Carlson et al.,
1989).
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It has been suggested that many of the family correlates of aggressive child
behaviour are present in infancy before the onset of the type of coercive cycles of
interaction that have formed the basis of many behavioural models of working
(Lyons-Ruth, 1996), and an early systematic review of 12 studies found that
parental sensitivity was a significant predictor of such security (De Wolff, 1997).
However, such sensitivity only explained around a third of the total variance, and
recent research has identified the importance of the specific nature or quality of
the attunement or contingency between parent and infant (Beebe et al., 2010),
the parent's capacity for what has been termed ‘maternal mind-mindedness'
(Meins et al., 2001) or 'reflective function' (Slade et al., 2001), and a range of
anomalous forms of parent-infant interaction (Lyons-Ruth, 2005).
A range of policy documents have now explicitly highlighted the importance of
promoting children’s wellbeing during the first two years of life (e.g. Field, 2010;
Allen, 2011; Munro, 2011; Tickell, 2011), and recent key documents include
Conception to Age 2: The Age of Opportunity (Wave Trust, 2013) and The 1001
Days: the Importance of Conception to Age 2 period (Cross Party Manifesto, 2014).
Fair Society, Healthy Lives (Marmot, 2010) highlighted the importance of both
pregnancy and the first two years of life in terms of equalising the life-chances of
children, and Our Health and Wellbeing Today (DH, 2010) similarly pointed to the
importance of ‘starting well’, focusing in particular on the health of mothers
during pregnancy, and parenting during the early years.
The promotion of parenting and emotional and behavioural wellbeing in children
is one of the explicit goals of the Healthy Child Programme (HCP), which is the
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key universal public health service for improving the health and wellbeing of
children, through health and development reviews, health promotion, parenting
support, and screening and immunisation programmes. Its goals are to identify
and treat problems early, help parents to care well for their children, change
health behaviours and protect against preventable diseases. The programme is
evidence-based and aims to prevent problems in child health and development,
and contribute to a reduction in health inequalities. The HCP is published in two
volumes – ‘Pregnancy and the First Five Years of Life’, and ‘From 5 to 19 Years
Old’. The evidence underpinning the current programme for 0-5 year-olds was
recently updated (Axford et al., 2015), and this paper presents the findings of
that review in terms of interventions that are aimed at improving attachment.
Method
A rapid review was undertaken of a range of electronic databases to identify
systematic reviews of interventions that met the agreed inclusion criteria. The
review also involved a search for randomised controlled trials (RCTs) published
during the relevant period that met the inclusion criteria and that had not been
included in one of the existing reviews. The search was undertaken as part of an
update of the Healthy Child Programme (DH, 2009), and therefore focuses
explicitly on evidence published since the previous update of the evidence
(Barlow et al., 2008). An advisory group of specialists across the UK was also
established to identify gaps in the evidence.
Inclusion criteria
Only studies that met the following inclusion criteria were included:
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Study design – systematic reviews, reviews of reviews and RCTs;
Intervention – any interventions provided on an individual or group basis,
and aimed at improving the attachment-related outcomes listed below;
Population – parents of preschool children;
Outcomes – parental sensitivity; parent-infant/toddler interaction;
attachment status etc.);
Years – a search was undertaken for systematic review studies during the
period January 2008 to July 2014 and for RCTs during the period January
2009 to November 2014.
Search terms and method
In order to identify studies meeting the inclusion criteria, relevant databases
were searched, including those of key organisations (e.g. Cochrane Collaboration,
NICE, EPPI Centre, Campbell Collaboration) and key electronic health, social
science and education databases (e.g. PubMed, PsychInfo, CINAHL). A full list of
search terms that were used can be found in the original report (see below for
address).
Experts in the respective fields covered were consulted and asked to identify any
systematic reviews or primary studies that were not identified by the search of
electronic databases.
Data synthesis
Data from each of the included reviews and primary studies are presented using
a narrative that both describes the intervention and summarises the results from
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the individual studies. This paper presents only the results focusing on
attachment, and a copy of the full report, including an assessment of the quality
of the included studies, is available online at:
https://www.gov.uk/government/publications/healthy-child-programme-
rapid-review-to-update-evidence.
Results
A total of 6 systematic reviews and 10 RCTs were identified. It should be noted
that because the findings presented represent an update of an existing review,
studies published prior to 2008 are not described below. We are not, however,
aware of any inconsistencies in terms of the findings of the current review and
those that were published prior to 2008. (Studies of sensitivity-based parenting
interventions for preterm infants are not presented here – see reviews by
Benzies et al. (2013) and Evans et al. (2014).
Infant massage
One systematic review was identified (Bennett et al., 2013), comprising 34 RCTs
involving healthy parent-infant dyads in which the infant was under the age of
six months. No significant differences were found for a range of aspects of infant
temperament, parent-infant interaction and mental development. The authors
concluded that the findings do not currently support the use of infant massage
with low-risk groups of parents and infants. They argue that there may be more
potential for change with demographically and socially deprived parent-infant
dyads, and that future research should focus on this.
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Video-feedback
Video-feedback involves a professional videotaping up to ten minutes of
interaction between carer and baby, returning subsequently to examine the tape
with the parent, and using the videotape to examine with the parent examples of
positive parent-infant interaction.
One review of 29 studies (13 RCTs, 8 QEDs, 8 pre-post design) examined the
effectiveness of video feedback on parental behaviours, sensitivity,
responsiveness, verbal and non-verbal communication, and child problem
behaviours (Fukkink, 2008). Of these, 23 included children aged under five
years. A meta-analysis showed a positive, statistically significant effect for video
feedback intervention on parenting behaviours. Brief video-feedback
interventions with parents in high-risk groups were the most effective. The
aggregate effect on child behaviour was described as being between ‘small’ and
‘average’. The authors concluded that family programmes that include video
feedback achieve the intended dual level effect: parents improve their
interaction skills, which in turn help in the development of their children.
Parents become more skilled in interacting with their young child and
experience fewer problems and gain more pleasure from their role as parent.
We identified five further recent RCTs that had evaluated the effectiveness of
video feedback with a range of high-risk parent-child dyads involving children
under the age of 5 years, including Canadian maltreating parents (Moss et al.,
2011), Portuguese parents living in poverty (Negrão et al., 2014), Turkish
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minority parents living in the Netherlands (Yagmur et al., 2014), mothers of
irritable infants (Cassidy et al., 2011) and Lithuanian mothers who were
identified as insensitive when their child was five months old (Kalinauskiene et
al., 2009).
Moss et al (2011) evaluated the effectiveness of a home delivered programme
using video interaction with maltreating parents. The programme consisted of
eight weekly home visits of approximately 90 minutes structured in four
sequences, including discussion on a parent-chosen theme, videotaped
interactive session, video feedback session and wrap-up session. The results of
an RCT involving 67 maltreating caregiver-child dyads found significant
improvements for the intervention group in parental sensitivity; more
intervention children became secure and fewer remained insecure and more
intervention children moved from being disorganised to organised. Older
children in the intervention group showed lower levels of internalising and
externalising problems (Moss et al., 2011).
Kalinauskiene et al. (2009) conducted an RCT of the video-feedback intervention
to promote positive parenting (VIPP) developed at Leiden University (Juffer et al.
2008) with 54 Lithuanian mothers rated low in sensitive responsiveness. The
intervention comprised five 90-minute sessions at home (the last one with
fathers) and was delivered by two clinical psychologists. Infants were aged 6
months and 12 days on average at the first visit. The intervention had a
statistically significant and large effect (d=0.78) on mothers’ sensitive
responsiveness. However, there was no effect on attachment security. The
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authors concluded that a relatively brief and low-cost programme can effectively
support mothers who lack sensitivity in the interactions with their infants.
Negrão et al. (2014) examined the use of VIPP-SD (Video-feedback Intervention
to promote Positive Parenting and Sensitive Discipline) with Portuguese mothers
of children between 1-4 years of age about whom there were concerns in terms
of their caregiving, and who were living in poverty. The work involved three
standard stages. The first two sessions focused primarily on building a
relationship with the mother, focusing on child behaviour and emphasising
positive interactions in the video feedback. The third and fourth sessions then
focused actively on improving parenting behaviours by showing the mother
when her parenting strategies work and to what other situations she could apply
these strategies. The final two sessions provided feedback and information from
the previous sessions in order to strengthen intervention effectiveness. In each
session, mother and child interaction was videotaped followed by feedback of
videos recorded in the previous session. Sessions 1-4 were scheduled at two-
week intervals. The last two “booster” sessions (5-6) were scheduled one-month
apart.
The results of a small RCT involving 55 families found significant improvements
favouring the intervention group in overall measures of maternal emotional
availability, child behaviour and family environment, with post hoc results
showing significant improvements in a number of domains: maternal non-
intrusiveness, child responsiveness and involvement. The domains of maternal
sensitivity, structuring and non-hostility also improved but failed to achieve
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significance. The results also showed a significant improvement in family
cohesion but not expressiveness or conflict.
Yagmur et al. (2014) evaluated the effectiveness of a culturally sensitive
adaptation of VIPP-SD for Turkish minority parents in the Netherlands (VIPP-
TM). The intervention involved six home visits lasting 2.5-3 hours over four
months. Visits were recorded, and used to illustrate themes. The results of an
RCT involving 86 mother-infant dyads found significant improvements favouring
the intervention groups for sensitive parenting and non-intrusiveness. There
was no effect on maternal discipline overall or on the subscales for laxness,
physical discipline, or supportive presence.
One study examined the effectiveness of an individually delivered version of the
group-based Circle of Security programme, which involves the use of videotaped
feedback to help the mother enhance her observation skills and to recognise
infant signals related to these needs (Cassidy et al., 2011). The programme also
helps parents to understand and manage psychological factors that may interfere
with their responses. This programme involved three one-hour home visits
every 3 weeks between 6.5 and 9 months. Approximately 2 weeks later, a final
visit is delivered during which the home visitor gives the mother a copy of
videotapes used in the intervention and discusses any ongoing parenting
concerns.
An RCT involving 220 parents and irritable infants found evidence of improved
attachment security for the highly (89% cf. 62%) but not moderately irritable
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infants (63% cf. 58%). Maternal security was also an important moderating
factor, with irritable infants of securely attached mothers being more likely to be
securely attached compared with no effect for moderately irritable infants of
securely attached mothers. For fearful mothers highly irritable infants were
equally likely to be secure in the intervention group (69% probability) and in the
control group (69% probability); similarly, for moderately irritable infants, no
effect of intervention emerged. For more dismissing mothers, the intervention
was efficacious for highly irritable infants but not for moderately irritable
infants of more dismissing mothers. In contrast, when mothers were classified as
preoccupied, there was evidence of an intervention effect for moderately
irritable infants, but not highly irritable infants.
Home visiting
We identified one systematic review evaluating the effectiveness of home visiting
on attachment-related outcomes (Nievar et al., 2010). Home visiting
programmes are manualised interventions that involve an intensive series of
home visits beginning prenatally (in some models only), and continuing during
the child’s first two years of life by specially trained personnel who provide
information, support and training regarding child health, development and care.
The programmes are multifaceted as regards the issues they address, but this is
driven largely by the theoretical underpinnings of the programme. Common
themes include early infant care, infant health and development and parenting
skills, but they may also include maternal health and well-being, diet, smoking,
drug/alcohol use, exercise, transition to parenthood and the parent’s
relationship with their partner.
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Nievar et al. (2010) included 35 controlled studies evaluating the effectiveness of
home visiting programmes and found that interventions were moderately
successful (d = .37) at improving maternal behaviours, as measured by a
combination of survey and observational measures that assessed the home
learning environment and maternal sensitivity.
Parent-infant/toddler psychotherapy
Parent-infant/child psychotherapy involves a therapist working with the parent
and infant/toddler together, establishing a therapeutic alliance with the parent
in order to identify unconscious patterns of relating in terms of the parents’ own
experiences of being parented and their internal working models. The aim of the
therapy is to help the parent to recognise the way in which their current
interactions are shaped by past experiences, in order to enable them to respond
more freely and sensitively to their infant.
One systematic review has evaluated the effectiveness of parent-infant/toddler
psychotherapy (Barlow et al., 2015). It included eight RCTs comparing the
effectiveness of parent-infant/toddler psychotherapy (PIP) with a no-treatment
control group (4 studies) or comparing PIP with other kinds of treatment
(including an infant led model of parent-infant psychotherapy, counselling/CBT
and interaction guidance). Meta-analyses indicated that parents who received
PIP were more likely to have an infant who was rated as being securely attached
to the parent after the intervention; however, there were no significant
differences in studies comparing outcomes of PIP with one of the other models of
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treatment (e.g. video interaction guidance, counselling, CBT). The authors
concluded that PIP is a promising model in terms of improving infant attachment
in high-risk families but that further research is needed into its impact on
potentially important mediating factors, such as mental health, reflective
functioning, and parent-infant interaction.
We identified one further RCT not included in the existing reviews evaluating the
effectiveness of parent child psychotherapy that was published within the
relevant time period. Ghosh Ippen et al. (2011) examined the effectiveness of a
standard parent-child psychotherapy intervention that was delivered by a
psychotherapist and involved a mean number of 32 weekly sessions of 60
minutes duration with both the parent and child aimed at enhancing the parent’s
capacity to provide safe and developmentally appropriate caregiving to the child.
The results of an RCT with 75 parent-child dyads involving preschool age
children (3-5 years) who had experienced multiple traumatic and stressful life
events found significant improvements favouring the intervention group for
PTSD (5% cf. 53%), child depression, co-occurring diagnoses, child behaviour,
maternal PTSD, and maternal depression.
Sensitivity and relationship-focused interventions
Two reviews were identified that examined a range of sensitivity- and
relationship-focused interventions in specific populations, including depressed
mothers (Kersten-Alvarez et al., 2011) and low-income mother-infant dyads
(Mortensen and MasterGeorge, 2014).
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Kersten-Alvarez et al (2011) included 10 controlled studies evaluating 13
preventive interventions (including interpersonal psychotherapy, non-directive
counseling, CBT, infant massage, home-based interaction coaching, parent
training, support group, and mother-infant therapy), aimed at improving
sensitivity in depressed mothers, and found a small-to-medium effect overall
(g=.32). Interventions providing infant massage were found to be highly
effective in improving maternal sensitivity.
Mortensen and MasterGeorge (2014) included 18 studies (15 of which were
RCTs) of 18 interventions (including home visiting, VIPP, Parent-Infant
Programme, Family Check-Up, and pregnancy programmes focusing on alcohol
use), all targeting low-income mother-child dyads. A meta-analysis found limited
evidence of effectiveness across all 18 relationship-based interventions.
However, the results were most effective for programmes that were shorter in
duration, provided direct services to the parent–child dyad used intervenors
with professional qualifications, and assessed parent-child interactions with
free-play tasks.
We identified one further RCT published within the review period that examined
the effectiveness of a group-based programme spanning the perinatal period
known as Mellow Babies in improving parent-infant interaction (Puckering et al.,
2010). Mellow Babies is a group-based day programme targeting women
experiencing depression and is underpinned by cognitive behavioural theory.
The intervention was delivered over 14 weeks, during which time mothers and
infants attended the group for a whole day (i.e. 10am – 3pm) on a weekly basis.
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Babies were cared for in the crèche in the morning, providing the mothers with
an opportunity to reflect on their own lives, draw links between past and present
feelings and relationships, and consider ways of managing depression using
broadly cognitive behavioural approaches. In the afternoon, participants
engaged in play-time involving interaction coaching, baby massage, looking at
picture books, lap games and nursery rhymes to promote sensitive interaction
and attunement. The babies were then returned to the crèche and the afternoon
sessions involved the use of videos of mothers interacting with their baby to
demonstrate sensitive interaction.
The results of a small RCT involving 20 mothers found significant improvements
in maternal depression and in parent-infant interaction in terms of positive
anticipation, positive responsiveness, negative autonomy and negative control.
There were also trends favouring the intervention group for negative distress,
positive control, positive co-co-operation and positive autonomy. There were no
significant differences between groups for positive distress, negative
anticipation, negative responsiveness or negative co-operation. No effect sizes
were provided.
Mentalisation-based programmes
We identified no reviews of mentalisation-based programmes, and two RCTs
published within the review period (Sadler et al 2013; Suchman et al 2011).
Sadler et al (2013) examined the effectiveness of a mentalisation-based home
visiting intervention focused on improving the reflective functioning of first-time
mothers aged 14-25 experiencing a range of problems – including child
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protection issues, depression, homelessness, poverty or violent relationships –
during the perinatal period. Minding the Baby (MTB) is a manualised
mentalisation-based interdisciplinary home visiting programme delivered by
two specially trained practitioners (nurse and social worker) in the home setting
over an extended period of time. (Mentalisation refers to envisioning mental
states in oneself and others and understanding behaviour in terms of mental
states.) Mothers are visited for an hour weekly beginning in the third trimester
of pregnancy through the child’s first birthday, at which point visits take place
biweekly through the child’s second birthday. Session length can vary based on
the client’s need. Clinicians (a qualified nurse and social worker alternate)
provide developmental guidance, crisis intervention, parenting support and
practical support in order to support reflective parenting, promote the mother-
infant attachment relationship, and model and foster a range of parenting skills.
The intervention was evaluated as part of an RCT (Sadler et al., 2013) involving
139 mothers of mostly Latina or African-American or Caribbean descent with
low education and income, some of whom (11%) had child protection concerns.
The results show that the intervention group mothers had fewer instances of
rapid subsequent childbearing and a trend toward fewer open cases with child
protection services than mothers in the control group (0% compared to 5%).
There were no significant differences between groups in maternal depression or
psychological distress but a trend toward improved communication for teenage
mothers – 67% of the intervention group teenage mothers versus 94% of the
control group had scores in the disrupted range. There were no group
differences in the reflective functioning of mothers, which improved in both
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groups. The study also found a significantly higher percentage of secure infants
in the MTB group (n=41, 64%) compared with the control group (n=30, 48%). In
addition, a significantly lower percentage of intervention group dyads (27%)
were classified as having disorganised attachment, compared with the control
group dyads (43%).
The second RCT evaluated the effectiveness of the Mothers and Toddlers
Programme (MTP), which comprises 12 weeks of individual therapy as an
adjunct to standard outpatient substance abuse treatment programmes. The aim
of MTP is to improve maternal capacity for reflective functioning and for
sensitivity and responsiveness to toddler emotional cues. The early sessions
focus on building a strong therapeutic alliance with the therapist and on
assisting the mother to address whatever challenging circumstances she is
facing, including both concrete (e.g. financial problems) and relational issues.
The next stage involves ‘ensuring that the mother has adequate support and
skills for tolerating and regulating strong affect (both positive and negative)’, and
the aim of this part of the therapy is ‘clarification of the mother’s
representational world’ with a view to identifying ‘areas of distortion, harshness,
incoherence, and insensitivity’ that can be explored with a view to developing a
more ‘coherent and integrated understanding of herself and her toddler’.
Attempts are made to link these representations with the way in which the
mother is interacting with others, including her baby, the ultimate objective
being to enable her to engage in a ‘mentalising process about the mother-child
relationship’. The therapy also involves exploring what emotions are elicited
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when she focuses on her toddler playing through the observation of videotaped
play sessions.
The results of this small RCT involving 47 women and their children found
moderately higher mean reflective functioning scores for the MTP group, and
slightly higher scores for coherence, sensitivity, and quality of representation
subscales for the MTP group, when compared with the comparison intervention
(Suchman et al., 2010). The results also showed an intervention effect of
improved caregiving behaviour for MTP mothers, and improved depression, and
global distress, but not for control group mothers. At six-week follow-up the
combined data for women receiving the 12- and 24-week programmes showed
that the higher mean reflective functioning score was maintained but reduced. At
follow-up there was also a slightly higher quality of maternal representation for
the MTP group, and moderately higher mean NCAST (Nursing Child Assessment
Satellite Training) scores for child communication with the mother for the MTP
group. However, effects for depression were not sustained at six-week follow-up
(Suchman et al., 2011).
Attachment and Biobehavioural Catchup (ABC)
We found no reviews but two studies published within the review period that
examined the effectiveness of the Attachment and Biobehavioural Catchup (ABC)
intervention with vulnerable parents of children under five years of age at risk of
maltreatment (Bernard et al., 2012; Lind et al., 2014).
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ABC is a manualised intervention that typically involves around 10 one-hour
sessions that focus primarily on providing parents with “in the moment”
feedback about their interactions with their child using video feedback to
highlight parents’ strengths, challenge weaknesses, and celebrate changes in
behaviours. Sessions 1 and 2 focused on providing nurturance when children are
distressed. Sessions 3 and 4 focused on behaving in synchronous ways (or
following the child’s lead with delight), and sessions 5 and 6 focused on avoiding
intrusive and frightening behaviour. Sessions 7 and 8 see the parent coach
discuss how the parent’s own attachment experiences may influence the parent’s
current interactions with their children. Sessions 9 and 10 help consolidate gains
made through the prior sessions and celebrate change (Lind et al., 2014).
Lind et al. (2014) examined the effectiveness of ABC with 260 US parents of
children under two years of age following allegations of maltreatment. The
results showed significant differences favouring the ABC group in terms of lower
levels of negative affect expression. Children in the ABC group displayed lower
overall levels of anger, lower levels of anger toward parent, and lower levels of
global anger/sadness.
Bernard et al. (2012) evaluated the effectiveness of ABC using an RCT involving
113 parents and young children (aged 1.7 to 21.4 months) at risk of
maltreatment, as indicated by recent contact with Child Protection Services. The
study found that a lower proportion of children in the ABC group (32%) were
classified as having a disorganised attachment compared with children in the
control group (57%) (this effect was sustained after excluding children over 24
21
months old at the time of assessment). Further, a higher proportion of children
in the ABC group were classified as securely attached (52%) compared with
children in the control group (33%), although this effect was not sustained after
children over 24 months old at the time of assessment were excluded.
Discussion
The results of this review of systematic reviews, and RCTs studies not included
in the reviews, show evidence of small to medium improvements in a range of
outcomes related to infant/child attachment security, including parental
sensitivity and reflective functioning. Although we have only included evidence
published since 2008, these results confirm the findings of earlier systematic
reviews (e.g. Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003; Barnes &
Freude-Lagevardi, 2003).
The theories of change underpinning the different programmes are diverse and
range from psychoanalytic models (e.g. parent-infant psychotherapy) that focus
primarily on changing the parents’ internal working models, through
programmes that focus explicitly on improving parents’ capacity for reflective
functioning (e.g. Minding the Baby, Mother and Toddler Programme), to those
that focus more explicitly on the interaction between the parent and
infant/toddler and on sensitive parenting, based on attachment theory (video
feedback and VIPP). There is, however, an increasing eclecticism, with
programmes drawing on different theoretical traditions, and almost all (apart
from the home visiting programmes) building in the use of video feedback.
22
There is also considerable divergence in terms of the frequency and duration of
interventions, with home visiting programmes such as Minding the Baby
involving intensive visits over a prolonged period of time and most other types
of programme involving intensive work over brief periods of time (e.g. a few
months) (e.g. Video-feedback and parent-infant psychotherapy). The limited
evidence available regarding the comparative effectiveness of these
interventions shows that there is little difference between them (Barlow et al.,
2015), and increasing evidence supporting the use of brief, sensitivity focused
interventions (cf. Bakermans-Kranenburg et al., 2003).
A number of implementation issues were identified. The Mortensen and
MasterGeorge (2014) review of interventions (including home visiting, VIPP,
parent-infant programme, Family Check-Up and pregnancy programmes
focusing on alcohol use) that targeted low-income mother-child dyads found that
the most effective programmes were shorter in duration, provided direct
services to the parent–child dyad, used intervenors with professional
qualifications, and assessed parent-child interactions with free-play tasks.
Of concern, however, is the fact that many of the identified interventions are not
currently routinely available to children, despite the high prevalence of
disorganised attachment in disadvantaged populations, and the strong
association between such attachment patterns and later problems.
Although some of these interventions require to be delivered by specialist
practitioners (e.g. psychologists and parent-child psychotherapists), many of the
23
remaining interventions are manualised (e.g. ABC, VIPP), and some can be
delivered effectively by health visitors as part of the Healthy Child Programme
(HCP) following appropriate training (e.g. video-feedback). It seems likely that
specialist CAMHS practitioners should have the necessary skills to deliver some
of these methods of working given the many preschool children presenting to
CAMHS services with severe emotional and behavioural problems.
Conclusion
This review has identified a number of innovative methods of working to
improve a range of attachment-related outcomes in preschool children, many of
whom could be defined as high risk. Despite the fact that both insecure and
disorganised attachment have a high prevalence in disadvantaged populations in
particular, and that both are strongly associated with a range of later problems,
including externalising and personality disorders, many of the methods of
working identified by this review are not yet routinely available to preschool
children in the UK. Practitioners working within a range of CAMHS settings
should have the skills to deliver some of the identified methods of working with
parent-child dyads, including video feedback and mentalisation-based
techniques.
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